Abdominal Aortic and Junctional Tourniquet … Abdominal Aortic and Junctional Tourniquet Controls...
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6 Abdominal Aortic and Junctional Tourniquet Controls Hemorrhage From a Gunshot Wound of the Left Groin John Croushorn, MD, FACEP ABSTRACT “Junctional hemorrhage” is defined as bleeding from the areas at the junction of the trunk and its append- ages. This is an important cause of potentially prevent- able deaths on the battlefield and a difficult condition to treat in the civilian prehospital setting. Having a so- lution to definitively treat the condition decreases the mortality and morbidity of these injuries. The Abdomi- nal Aortic and Junctional Tourniquet ™ is (1) a Food and Drug Administration–cleared device that is currently indicated for pelvic, inguinal, and axillary bleeding; (2) the only junctional tourniquet with an indication for pelvic bleeding; (3) the only junctional tourniquet re- ported with a successful axillary use; and (4) effective at lower tissue pressures than other junctional tourniquets available. KEYWORDS: Abdominal Aortic and Junctional Tourniquet, hemorrhage, gunshot wound Introduction Junctional hemorrhage is defined as bleeding from the areas at the junction of the trunk and its appendages. This is an important cause of potentially preventable deaths on the battlefield and a difficult condition to treat in the civilian prehospital setting. Having a solution to definitively treat the condition decreases the mortality and morbidity resulting from these injuries. The U.S. military has identified junctional hemorrhage control as an important capability gap in military medi- cine. 1 One recent review of battle casualties found that 21% of casualties who died of wounds had junctional bleeding, possibly amenable to a truncal tourniquet. 2 The Abdominal Aortic Tourniquet ™ (AAT) was applied to a Soldier with multiple life-threatening injuries in Afghanistan in 2013. 3,4 The AAT rapidly stopped the bleeding and freed the hands of medical providers to perform other lifesaving prehospital interventions on the wounded patient. The AAT was applied to an axillary wound in the patient who had lost 6 cm of his axillary artery. It successfully stopped the hemorrhage and al- lowed the patient to be resuscitated and to undergo surgery. The patient successfully survived the surgery and recovered to walk out of the hospital. 5 In December 2013, the AAT was renamed Abdominal Aortic and Junctional Tourniquet ™ (AAJT) (http://www .compressionworks.net) and received new indications from the U.S. Food and Drug Administration to treat pelvic bleeding and bleeding in the inguinal region and axilla. The device placement also was changed to allow for individual groin application and axillary placement, as outlined in the previously described case study. The present case report describes an on-label use of the AAJT in the groin and demonstrates its safety and ef- fectiveness in stopping hemorrhage from a challenging wound. Case Presentation A 21-year-old man was driven to the main entrance of the emergency department. The patient had sustained three gunshot wounds to his lower extremities. His right leg sustained two of these wounds, and his left leg sustained the third wound. The right leg wounds were not bleeding: They were to the right ankle and right mid-inner thigh. The latter had only one wound, and radiography demonstrated a retained bullet. The left leg wound was to the proximal thigh. A small entry wound was located laterally, and a large exit wound was lo- cated in the proximal medial thigh. A large amount of blood was noted in the patient’s pants. The proximal left thigh wound was bleeding profusely when exposed. The patient was lethargic. He was brought to a resuscitation room, and direct manual pressure was applied to the left groin wound to control the hemorrhage. The diaphoretic patient was arousable but confused. The primary emergency physician focused on hemor- rhage control, and a partner focused on assessing the airway. Monitoring at that time showed a heart rate of 150 beats/min (bpm); however, blood pressure was too low to be detected when measurement was attempted. A thready carotid pulse was noted. With tachycardia, unobtainable blood pressure, and lethargic state, the
Transcript of Abdominal Aortic and Junctional Tourniquet … Abdominal Aortic and Junctional Tourniquet Controls...
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Abdominal Aortic and Junctional Tourniquet Controls Hemorrhage
From a Gunshot Wound of the Left Groin
John Croushorn, MD, FACEP
ABSTRACT“Junctional hemorrhage” is defined as bleeding from the areas at the junction of the trunk and its append-ages. This is an important cause of potentially prevent-able deaths on the battlefield and a difficult condition to treat in the civilian prehospital setting. Having a so-lution to definitively treat the condition decreases the mortality and morbidity of these injuries. The Abdomi-nal Aortic and Junctional Tourniquet™ is (1) a Food and Drug Administration–cleared device that is currently indicated for pelvic, inguinal, and axillary bleeding; (2) the only junctional tourniquet with an indication for pelvic bleeding; (3) the only junctional tourniquet re-ported with a successful axillary use; and (4) effective at lower tissue pressures than other junctional tourniquets available.
Keywords: Abdominal Aortic and Junctional Tourniquet, hemorrhage, gunshot wound
IntroductionJunctional hemorrhage is defined as bleeding from the areas at the junction of the trunk and its appendages. This is an important cause of potentially preventable deaths on the battlefield and a difficult condition to treat in the civilian prehospital setting. Having a solution to definitively treat the condition decreases the mortality and morbidity resulting from these injuries.
The U.S. military has identified junctional hemorrhage control as an important capability gap in military medi-cine.1 One recent review of battle casualties found that 21% of casualties who died of wounds had junctional bleeding, possibly amenable to a truncal tourniquet.2 The Abdominal Aortic Tourniquet™ (AAT) was applied to a Soldier with multiple life-threatening injuries in Afghanistan in 2013.3,4 The AAT rapidly stopped the bleeding and freed the hands of medical providers to perform other lifesaving prehospital interventions on the wounded patient. The AAT was applied to an axillary wound in the patient who had lost 6 cm of his axillary artery. It successfully stopped the hemorrhage and al-lowed the patient to be resuscitated and to undergo
surgery. The patient successfully survived the surgery and recovered to walk out of the hospital.5
In December 2013, the AAT was renamed Abdominal Aortic and Junctional Tourniquet™ (AAJT) (http://www .compressionworks.net) and received new indications from the U.S. Food and Drug Administration to treat pelvic bleeding and bleeding in the inguinal region and axilla. The device placement also was changed to allow for individual groin application and axillary placement, as outlined in the previously described case study.
The present case report describes an on-label use of the AAJT in the groin and demonstrates its safety and ef-fectiveness in stopping hemorrhage from a challenging wound.
Case PresentationA 21-year-old man was driven to the main entrance of the emergency department. The patient had sustained three gunshot wounds to his lower extremities. His right leg sustained two of these wounds, and his left leg sustained the third wound. The right leg wounds were not bleeding: They were to the right ankle and right mid-inner thigh. The latter had only one wound, and radiography demonstrated a retained bullet. The left leg wound was to the proximal thigh. A small entry wound was located laterally, and a large exit wound was lo-cated in the proximal medial thigh. A large amount of blood was noted in the patient’s pants. The proximal left thigh wound was bleeding profusely when exposed. The patient was lethargic. He was brought to a resuscitation room, and direct manual pressure was applied to the left groin wound to control the hemorrhage.
The diaphoretic patient was arousable but confused. The primary emergency physician focused on hemor-rhage control, and a partner focused on assessing the airway. Monitoring at that time showed a heart rate of 150 beats/min (bpm); however, blood pressure was too low to be detected when measurement was attempted. A thready carotid pulse was noted. With tachycardia, unobtainable blood pressure, and lethargic state, the
AAJT Controls Hemorrhage From Left Groin GSW 7
patient was assessed to be in hemorrhagic shock. Four units of emergent O-negative packed red blood cells (PRBCs) were requested; they were at the bedside 12 minutes after the patient’s arrival.
A Combat Application Tourniquet® (CAT) (North Amer-ican Rescue LLC; http://www.narescue.com) was applied proximal to the wound, and bleeding stopped (Figure 1). After the second unit of PRBCs and the first liter of normal saline were transfused, the patient became more alert and began complaining of the discomfort from the CAT tourniquet. His systolic blood pressure was mea-sured at 75mmHg. His heart rate decreased to 130 bpm. At this time, bleeding was noted from the inner proximal thigh wound on the left leg. An attempt to place a second CAT tourniquet was made; however, the first CAT tour-niquet abutted the perineum, and there was no room for a second tourniquet to be placed above the first.
The AAJT was applied by the primary emergency physi-cian around the hips, with the bladder against the left groin (Figure 2). The belt was tightened, the windlass then was tightened and secured, and the bladder was inflated until the manometer showed green, indicating 250mmHg pressure. The CAT was kept in place, but the tension was released. The wounds were reassessed, and no blood loss was found to have occurred. The patient commented that the AAJT was more comfortable than the CAT.
The patient was assessed surgically and thought to be stable enough to transfer to a Level I trauma center for further resuscitative measures and vascular repair. Before transfer, the patient received a third and fourth unit of emergent O-negative PRBCs. He received a sec-ond liter of normal saline. At the time of transfer, his blood pressure was 101/50mmHg, and he had a pulse rate of 102. He was alert and oriented. The patient was
transferred from the emergency department to the Level I trauma center via Advanced Life Support (ALS) am-bulance with a nurse (Figure 3). Throughout transport and movement to the trauma unit, the AAJT remained inflated, and no blood loss was noted from the proximal left leg wound.
On vascular surgery, a transsection of the left deep fem-oral artery was noted. The artery was ligated. No other significant arterial injury was found. The patient recov-ered and walked out of the hospital on postoperative day 3. Posthospitalization follow-up has continued to show no complications related to the use of the AAJT.
Lessons LearnedThe AAJT was quickly applied over the hips and po-sitioned over the groin. Slack removal is essential for
Figure 1 Initial use of the CAT in the emergency department. The proximal femoral wound is seen with initial hemostasis noted.
Figure 2 The AAJT is applied to the left groin. The CAT has been left in place but loosened. The wound is seen just to the left of the CAT.
Figure 3 The patient is prepared for transport to the Level 1 trauma center. The AAJT is applied to the left groin. The CAT is loose but in place. The patient is awake and hemodynamically stable.
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optimal use of any circumferential tourniquet. Once the slack was removed, the windlass was tightened and se-cured. The device was fully inflated to the green indicator, which measures pressures of 250–300mmHg. There was no blood flow from the wound at an inflation pressure be-low 250mmHg. In the human research for FDA clearance, the AAJT was noted to be effective in the inguinal region at lower pressures than the original abdominal placement. The pressure for occlusion of blood flow to the femoral ar-tery was 148.5mmHg in 100% of the subjects. There may be benefits in a gauge that indicates this lower pressure during application as sufficient for the groin. Likewise, the human research for the axillary placement showed 100% effectiveness on all patients at 168mmHg.
The AAJT is (1) an FDA-cleared device that is currently indicated for pelvic, inguinal, and axillary bleeding; (2) the only junctional tourniquet with an indication for pel-vic bleeding; (3) the only junctional tourniquet reported with a successful axillary use; and (4) effective at lower tis-sue pressures than other junctional tourniquets available.
DisclosureDr. Croushorn is one of the inventors of the AAJT and president of Compression Works LLC (http://www
.compressionworks.net/), which developed and manu-factures the device.
References1. Kragh JF Jr, Murphy C, Dubick MA, et al. New tourni-
quet device concepts for battlefield hemorrhage control. US Army Med Department J. 2011;38–48, 2011.
2. Eastridge BJ, Hardin M, Cantrell J, et al. Died of wounds on the battlefield: causation and implications for improv-ing combat casualty care. J Trauma Acute Care Surg, 2011; 71:S4–S8.
3. Case Report: Abdominal Aortic Tourniquet use in Afghani-stan. J Spec Oper Med. 2013;13:1–2.
4. Croushorn J, Calloway D. Abdominal Aortic Tourniquet Commentary. J Spec Oper Med. 2013;13:3.
5. Case Report: Abdominal Aortic Tourniquet controls junc-tional hemorrhage from a gunshot wound of the axilla. J Spec Oper Med. 2013;13:1–4.
Dr. Croushorn has been involved in hemorrhage control re-search since 2005. He is a board-certified emergency physi-cian who lives in Birmingham, AL. He was a former command surgeon, Task Force 185, OIF 2004. E-mail: [email protected].
